Preoperative detection of hepatocellular carcinoma's microvascular invasion on CT-scan by machine learning and radiomics: A preliminary analysis

INTRODUCTION

Microvascular invasion (MVI) is the main risk factor for overall mortality and recurrence after surgery for hepatocellular carcinoma (HCC).The aim was to train machine-learning models to predict MVI on preoperative CT scan.

METHODS

3-phases CT scans were retrospectively collected among 4 Italian centers. DICOM files were manually segmented to detect the liver and the tumor(s). Radiomics features were extracted from the tumoral, peritumoral and healthy liver areas in each phase. Principal component analysis (PCA) was performed to reduce the dimensions of the dataset. Data were divided between training (70%) and test (30%) sets. Random-Forest (RF), fully connected MLP Artificial neural network (neuralnet) and extreme gradient boosting (XGB) models were fitted to predict MVI. Prediction accuracy was estimated in the test set.

RESULTS

Between 2008 and 2022, 218 preoperative CT scans were collected. At the histological specimen, 72(33.02%) patients had MVI. First and second order radiomics features were extracted, obtaining 672 variables. PCA selected 58 dimensions explaining >95% of the variance.In the test set, the XGB model obtained Accuracy = 68.7% (Sens: 38.1%, Spec: 83.7%, PPV: 53.3% and NPV: 73.4%). The neuralnet showed an Accuracy = 50% (Sens: 52.3%, Spec: 48.8%, PPV: 33.3%, NPV: 67.7%). RF was the best performer (Acc = 96.8%, 95%CI: 0.91-0.99, Sens: 95.2%, Spec: 97.6%, PPV: 95.2% and NPV: 97.6%).

CONCLUSION

Our model allowed a high prediction accuracy of the presence of MVI at the time of HCC diagnosis. This could lead to change the treatment allocation, the surgical extension and the follow-up strategy for those patients.

Liver transplantation for gastroenteropancreatic neuroendocrine liver metastasis: optimal patient selection and perioperative management in the era of multimodal treatments

Gastroenteropancreatic neuroendocrine tumors (NET) often metastasize to the liver. Although curative liver resection provides a favorable prognosis for patients with neuroendocrine liver metastasis (NELM), with a 5-year survival rate of 70-80%, recurrence is almost inevitable, mainly in the remnant liver. In Western countries, liver transplantation (LT) has been performed in patients with NELM, with the objective of complete removal of macro- and micro-NELMs. However, prognosis had been unsatisfactory, with 5-year overall survival and recurrence-free survival rates of approximately 50 and 30%, respectively. In 2007, the Milan criteria were proposed as indications for LT for NELM. The criteria included: (1) confirmed histology of NET-G1 or G2; (2) a primary tumor drained by the portal system and all extrahepatic diseases removed with curative resection before LT; (3) liver involvement ≤50%; (4) good response or stable disease for at least 6 months before LT; (5) age ≤ 55 years. A subsequent report demonstrated outstanding LT outcomes for NELM within the Milan criteria, with 5-year overall survival and recurrence rates of 97 and 13%, respectively. In Japan, living donor LT (LDLT) for NELM has been performed sporadically in only 16 patients by 2021 in Japan; however, no consensus has been reached on the indications or perioperative management of LDLT. This article presents the outcomes of these 16 patients who underwent LDLT in Japan and reviews the literature to clarify optimal indications and perioperative management of LDLT for NELM in the era of novel multimodal treatments.

Comparison of Vascular Complications Between Living-donor and Deceased-donor Liver Transplantation - A Systematic Review and Meta-analysis

BACKGROUND

Vascular complications commonly cause graft loss and morbidity after liver transplantation (LT). Comparative data on the risk of vascular complications are limited. Hence, the present meta-analysis was conducted to analyze the difference in vascular complications between living-donor LT (LDLT) and deceased-donor LT (DDLT).

METHODS

A literature search of three databases was conducted for studies comparing the incidence of vascular complications with LDLT and DDLT. The event rates and odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model.

RESULTS

A total of 20 studies were included in the final analysis. There was no difference in the incidence of overall vascular complications (9.3%, 95% CI: 6.6-12.0 vs. 8.5%, 95% CI: 5.6-11.4) between LDLT and DDLT with OR 0.94 (95% CI: 0.73-1.21) (15 studies).There was a higher incidence of vascular complications with LDLT in older studies (published before 2013) but not in new studies. When comparing the individual complications, LDLT was associated with a higher incidence of hepatic artery thrombosis (HAT) (3.8%, 95% CI: 2.4-5.2 vs. 1.6%, 95% CI: 1.1-2.2)with OR 2.20 (95% CI: 1.53-3.17) (14 studies)and a significantly lower incidence of intra-abdominal bleeding(4.8%, 95% CI: 3.3-6.2 vs. 7.9%, 95% CI: 5.0-10.7) with OR 0.64 (95% CI: 0.47-0.87) (11 studies). However, there was no difference in the incidence (2.1%, 95% CI: 0.5-3.8 vs. 1.0%, 95% CI: 0.1-1.9) of portal vein thrombosis between LDLT and DDLT with OR 1.85 (95% CI: 0.82-4.18) (6 studies).

CONCLUSION

Despite a comparable risk of vascular complications between LDLT and DDLT, LDLT was associated with a higher risk of HAT and a lower risk of intraprocedural bleeding. Further studies are required to analyze the effect of donor-recipient characteristics and surgical techniques on the risk of vascular complications.

Transarterial Radioembolization Can Downstage Intermediate and Advanced Hepatocellular Carcinoma to Liver Transplantation

BACKGROUND

Transarterial radioembolization (TARE) is an effective treatment to control tumor growth and improve survival in hepatocellular carcinoma (HCC). The role of TARE in downstaging patients to liver transplantation (LT) is unclear. The aim of this study was to investigate the downstaging efficacy of TARE for intermediate and advanced HCC.

METHODS

Intention-to-treat analysis with multistate modeling was performed. Patients moved through 5 health states: (1) from TARE to listing, (2) from TARE to death without listing, (3) from listing to LT, (4) from listing to death without LT, and (5) from transplant to death. Factors affecting the chance of death after TARE were considered to stratify outcomes.

RESULTS

Two hundred fourteen patients underwent TARE. Of those, 43.9% had radiological response, 29.9% were listed, and 22.8% were transplanted. The probability of being alive without LT was 40.5% 1 y after TARE and 11.5% at 5 y. The chance of being listed was 9.4% at 1 y and 0.9% at 5 y. The probability of dying after TARE without LT was 38% at 1 y and 73% at 5 y. The overall survival of patients receiving LT was 61% at 5 y after transplant. Tumor beyond up-to-seven criteria, alfafetoprotein >400 ng/mL, and albumin-bilirubin ≥2 were associated with death. Three risk groups were associated with different response, chances of being listed, and receiving LT. Median survival was 3 y for low-risk, 1.9 y for intermediate-risk, and 9 mo for high-risk patients ( P  < 0.001).

CONCLUSIONS

In intermediate and advanced HCC, TARE allows for a 44% chance of response, 30% downstaging, and 23% probability of permitting LT. Patient's and tumor's characteristics allow for risk stratification and predict survival from TARE.

Recipient-Donor Sex Constellation in Liver Transplantation for Hepatocellular Carcinoma-An ELTR Study

BACKGROUND & AIMS

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Liver transplantation (LT) is a curative treatment option. We investigated survival outcomes based on recipient-donor sex constellation (RDSC) following LT.

METHODS

We performed a European Liver Transplant Registry analysis, including patients from 1988 to December 2022. The cohort was split into four RDSC groups: female donor female recipient (FDFR), female donor male recipient (FDMR), male donor female recipient (MDFR) and male donor male recipient (MDMR). Survival analysis, including death with recurrence, was performed.

RESULTS

In 7601 LT for HCC with an overall median follow-up of 22.6 months (5.8, 60.7), death was registered in 25.1% and, as primary cause of death, HCC tumour recurrence in 26.0%. There was no statistically significant difference on crude survival estimates among the different RDSC groups (log-rank p = 0.66) with 10-year overall survival (OS) of 54.5% in FDFR, 54.6% in FDMR, 59.1% in MDFR and 56.9% in MDMR. On multivariable analysis, RDSC showed a significant effect on OS (FDFR as reference): MDFR (aHR 0.72, p = 0.023). No significant difference was found for FDMR (aHR 0.98, p = 0.821) and MDMR (aHR 0.90, p= 0.288). Regarding overall registered causes of death, differences between RDSC groups were found in rejection (p = 0.017) and cardiovascular (p = 0.046) associated deaths.

CONCLUSIONS

In female recipients undergoing LT for HCC, male donor grafts were associated with a 28% reduction of mortality compared to female donor grafts.

Attenuation Measuring Ultrasound Shearwave Elastography (AMUSE) as Noninvasive Imaging Biomarker for Liver Acute Cellular Rejection

OBJECTIVE

There are over 9000 liver transplants in the United States per year, with acute cellular rejection (ACR) being a prevalent early post-transplant complication (20%-40%) treated using corticosteroids. Ischemia-reperfusion injury (IRI), another early post-transplant pathology, has similar laboratory results but typically resolves without therapy. ACR confirmation requires invasive liver biopsy, bearing risks like hemorrhage and pneumothorax. Attenuation Measuring Ultrasound Shearwave Elastography (AMUSE) assesses shear wave velocity (c) and attenuation (α) without rheological models and have shown potential for noninvasive tissue characterization.

METHODS

We analyzed 58 transplanted livers suspected for ACR by comparing AMUSE measurements to biopsy findings. Thirteen patients underwent longitudinal tracking from ACR diagnosis on day 7 to therapy initiation and repeat biopsy on day 14. Statistical methods and support vector machine (SVM) were used for performance analysis.

RESULTS

AMUSE measurements at 100, 200, and 300 Hz showed statistical significance (p < 0.001) for ACR presence, with 200 Hz exhibiting the highest Spearman correlation coefficients for c and α (0.68 and -0.83). High c (> 2.2 m/s) and low α (< 130 Np/m) at 200 Hz correlated with ACR diagnostic, while low c and high α indicated no ACR. Combining c and α into a single biomarker α/c improved patient differentiation, yielding an F1-score of 0.97. SVM was used to evaluate AMUSE ACR staging capabilities using all available frequencies, reaching 0.95 F1-score for categorical classification, with an AUROC of 0.99. When evaluating the presence of ACR the SVM reached 0.99 F1-score, with 1.00 sensitivity/recall.

CONCLUSION

These findings support the use of AMUSE potential for detection and staging of liver ACR.

Acquired ductopenia: an insight into imaging findings

Hepatic ductopenia is a pathologic diagnosis characterized by a decrease in the number of intrahepatic bile ducts as a consequence of various underlying etiologies. Some etiologies, such as primary sclerosing cholangitis, primary biliary cholangitis, and ischemic cholangitis, often have distinctive imaging findings. In contrast, other causes such as chronic rejection following liver transplantation, drug-induced biliary injury, infection, malignancy such as lymphoma, and graft-versus-host disease may only have ancillary or non-specific imaging findings. Thus, diagnosing ductopenia in conditions with nonspecific imaging findings requires a multidimensional approach, including clinical evaluation, serological testing, imaging, and liver histology to identify the underlying cause. These etiologies lead to impaired bile flow, resulting in cholestasis, liver dysfunction, and, ultimately, cirrhosis and liver failure if the underlying cause remains untreated or undetected. In the majority of instances, individuals diagnosed with ductopenia exhibit a positive response to treatment addressing the root cause or cessation of the causative agent. This article focuses on acquired causes of ductopenia, its clinical manifestation, histopathology, imaging diagnosis, and management.

Future of U.S. living donor liver transplant: Donor and recipient criteria, transplant indications, transplant oncology, liver paired exchange, and non-directed donor graft allocation

In the United States, living donor liver transplant (LDLT), from both directed and nondirected living donors, has expanded over the past several years. LDLT is viewed as an important opportunity to expand the overall donor pool for liver transplantation (LT), shorten waiting times for a life-prolonging LT surgery, and reduce LT waitlist mortality. The LT community's focus on LDLT expansion in the United States is fostering discussions around future opportunities, which include the safe expansion of donor and recipient candidate eligibility criteria, broadening indications for LDLT including applications in transplant oncology, developing national initiatives around liver paired exchange, and maintaining vigilance to living donor and recipient candidate risk/benefit equipoise. Potential opportunities for expanding living liver donor and recipient candidate criteria include using donors with more than minimal hepatic steatosis, evaluating older donors, performing LDLT in older recipients to facilitate timely transplantation, and providing candidates who would benefit from an LT, but may otherwise have limited access (ie, lower MELD scores), an avenue to receive a life-prolonging organ. Expansion opportunities for LDLT are particularly robust in the transplant oncology realm, including leveraging LDLT for patients with advanced HCC beyond Milan, intrahepatic cholangiocarcinoma, and nonresectable colorectal cancer liver metastases. With ongoing investment in the deliberate growth of LDLT surgical expertise, experience, and technical advances in the United States, the LT community's future vision to increase transplant access to more patients with end-stage liver disease and selected oncology patients may be successfully realized.

Full Robotic Whole Graft Liver Transplantation: A Step Into The Future

OBJECTIVE

To report the first European series of full robotic whole liver transplantation (RLT) with technical details and future perspectives.

BACKGROUND

Few cases of liver transplantation with a minimally invasive approach using partial grafts have been reported so far, and no cases of robotic whole liver transplantation have been reported in the scientific literature.

METHODS

The adopted technique was full robotic liver hepatectomy, followed by robotic implantation after graft introduction through a small midline incision. Patients presenting with hepatocellular carcinoma in liver cirrhosis with a small caudate lobe, low degree of portal hypertension, no porto-mesenteric thrombosis, as well as low Model for End-Stage Liver Disease patients have been considered ideal candidates.

RESULTS

Six patients underwent RLT between February and March 2024 at Lisbon and Modena University Liver Transplant Centers. Warm ischemia time during RLT ranged between 55 and 90 minutes, with a total surgery duration between 440 and 710 minutes. The median total operative time was 595 (±111.3) minutes. Only 1 recipient had prolonged hyperbilirubinemia, which was safely treated. The median in-hospital stay was 7.5 days (±4.8 d).

CONCLUSIONS

RLT is a promising technique to further reduce the impact of liver transplantation thanks to smaller incision, gentle tissue manipulation, high magnification and precision for vascular and biliary anastomosis, and reduced postoperative pain. This is the first step toward the demonstration of the feasibility of minimally invasive surgery in liver transplantation, although further selection and technical refinements are needed to improve reproducibility.

Comparison of Clinical Outcomes Using Left and Right Liver Grafts in Adult-to-adult Living-donor Liver Transplantation: A Retrospective Cohort Study Using the Korean Organ Transplantation Registry

BACKGROUND

Living-donor liver transplantation has been widely performed as an alternative to the scarce liver grafts from deceased donors. More studies are reporting favorable outcomes of left liver graft (LLG). This study compared the clinical outcomes between living-donor liver transplantation using LLG and right liver graft (RLG) with similar graft-to-recipient body weight ratios.

METHODS

This study analyzed 4601 patients from a multicenter observational cohort using the Korean Organ Transplantation Registry between 2014 and 2021. After matching the Model for End-stage Liver Disease score and graft-to-recipient body weight ratios because of the extremely different number in each group, the LLG and RLG groups comprised 142 (25.1%) and 423 (74.9%) patients, respectively.

RESULTS

For donors, the median age was higher in the LLG group than in the RLG group (34 y [range, 16-62 y] versus 30 y [16-66 y] ; P  = 0.002). For recipients, the LLG group showed higher 90-d mortality than the RLG group (11 [7.7%] versus 9 [2.1%]; P  = 0.004). The long-term graft survival was significantly worse in the LLG group ( P  = 0.011). In multivariate Cox proportional hazards regression analysis for graft survival, LLG was not a significant risk factor (hazard ratio, 1.01 [0.54-1.87]; P  = 0.980). Otherwise, donor age (≥40 y; 2.18 y [1.35-3.52 y]; P  = 0.001) and recipients' body mass index (<18.5 kg/m 2 ; 2.98 kg/m 2 [1.52-5.84 kg/m 2 ]; P  = 0.002) were independent risk factors for graft survival.

CONCLUSIONS

Although the short-term and long-term graft survival was worse in the LLG group, LLG was not an independent risk factor for graft survival in multivariate analysis. LLGs are still worth considering for selected donors and recipients regarding risk factors for graft survival.

Liver Resection for Hepatocellular Carcinoma: Recent Advances

Hepatocellular carcinoma (HCC) represents a significant global health burden. Surgery remains a cornerstone in the curative treatment of HCC, and recent years have witnessed notable advancements aimed at refining surgical techniques and improving patient outcomes. This review presents a detailed examination of the recent innovations in HCC surgery, highlighting key developments in both surgical approaches and adjunctive therapies. Advanced imaging technologies have revolutionized preoperative assessment, enabling precise tumour localization and delineation of vascular anatomy. The use of three-dimensional rendering has significantly augmented surgical planning, facilitating more accurate and margin-free resections. The advent of laparoscopic and robotic-assisted surgical techniques has ushered in an era of minimal access surgery, offering patients the benefits of shorter hospital stays and faster recovery times, while enabling equivalent oncological outcomes. Intraoperative innovations such as intraoperative ultrasound (IOUS) and fluorescence-guided surgery have emerged as valuable adjuncts, allowing real-time assessment of tumour extent and aiding in parenchyma preservation. The integration of multimodal therapies, including neoadjuvant and adjuvant strategies, has allowed for 'bio-selection' and shown the potential to optimize patient outcomes. With the advent of augmented reality and artificial intelligence (AI), the future holds immense potential and may represent significant strides towards optimizing patient outcomes and refining the standard of care.

Role of locoregional therapy including liver transplantation in liver-only metastatic colorectal cancer: a review paper

INTRODUCTION

Resection of primary tumor and liver metastases is the gold standard for colorectal cancer with liver-only metastases (CRLM). Although treatment options have expanded to enable conversion of unresectable to resectable CRLM, about 40% of patients will have definitively unresectable disease. Major advances in surgical techniques, immunosuppressive protocols and patient selection criteria for liver transplantation have resulted in improved outcomes.

AREAS COVERED

A literature search has been conducted in Pubmed for articles published between 2014 and 2024. This review paper comments on current liver-directed treatment options for CRLM: resection, percutaneous ablation, conversion-chemotherapy, TACE, SIRT, and SABR. We explore evidence for liver transplantation in patients with unresectable CRLM, comment on possible limitations for implementation in clinical practice and give an overview of the current guidelines on liver transplantation in the USA, Europe, the United Kingdom, and Australia/New Zealand.

EXPERT OPINION

The recent randomized TRANSMET trial, investigating liver transplantation versus chemotherapy in unresectable CRLM, shows promising 5-year OS reaching similar values as for other accepted liver transplantation indications. Further investigations with RCTs to investigate reproducibility and feasibility in clinical practice are needed. Before liver transplantation can be implemented as a standard treatment option, reorganizations at federal, regional and hospital levels would be required.

Implementation of a multicomponent medication adherence promotion system is associated with a decrease in late T-cell-mediated rejection

Poor immunosuppression adherence in pediatric recipients of liver transplant (LT) contributes to late T-cell-mediated rejection (TCMR) in ~90% of cases and increases the risk of mortality. A medication adherence promotion system (MAPS) was found to reduce late rejection in pediatric recipients of kidney transplants. Using quality improvement methodology, we adapted and implemented the MAPS in our LT clinic. Our primary outcome was population-level rates of late TCMR, measured as a monthly incident rate. Three-hundred fourteen patients undergoing LT are currently cared for at our institution. One-hundred sixty-two (52%) are females with a median age of 16 years and a median age at LT of 2 years. Preimplementation, monthly rejection rates were 0.84 rejections per 100 patient-months. After iterative implementation of MAPS over 2.3 years, monthly rejection rates decreased to 0.46 rejections per 100 patient-months, a 45% decrease in late TCMR. Implementation of MAPS was associated with a sustained 45% decrease in TCMR at a single center, suggesting that quality improvement tools may help improve clinical outcomes. MAPS may be an important tool to ensure long-term allograft health. Future studies should rigorously test MAPS across a multicenter sample.

Abdominal surgery in patients with chronic noncirrhotic extrahepatic portal vein obstruction: A multicenter retrospective study

BACKGROUND AND AIMS

In patients with noncirrhotic chronic extrahepatic portal vein obstruction (EHPVO), data on the morbimortality of abdominal surgery are scarce.

APPROACH AND RESULTS

We retrospectively analyzed the charts of 76 patients (78 interventions) with EHPVO undergoing abdominal surgery within the Vascular Disease Interest Group network. Fourteen percent of the patients had ≥1 major bleeding (unrelated to portal hypertension) and 21% had ≥1 Dindo-Clavien grade ≥3 postoperative complications within 1 month after surgery. Fifteen percent had ≥1 portal hypertension-related complication within 3 months after surgery. Three patients died within 12 months after surgery. An unfavorable outcome (ie, ≥1 abovementioned complication or death) occurred in 37% of the patients and was associated with a history of ascites and with nonwall, noncholecystectomy surgical intervention: 17% of the patients with none of these features had an unfavorable outcome, versus 48% and 100% when one or both features were present, respectively. We then compared 63/76 patients with EHPVO with 126 matched (2:1) control patients without EHPVO but with similar surgical interventions. As compared with control patients, the incidence of major bleeding ( p <0.001) and portal hypertension-related complication ( p <0.001) was significantly higher in patients with EHPVO, but not that of grade ≥3 postoperative complications nor of death. The incidence of unfavorable postoperative outcomes was significantly higher in patients with EHPVO than in those without (33% vs. 18%, p =0.01).

CONCLUSIONS

Patients with EHPVO are at high risk of major perioperative or postoperative bleeding and postoperative complications, especially in those with ascites or undergoing surgery other than wall surgery or cholecystectomy.

Benefits of liver transplant in critically ill patients with acute-on-chronic liver failure: Implementation of an urgent living-donor program

We evaluated the liver transplantation (LT) criteria in acute-on-chronic liver failure (ACLF), incorporating an urgent living-donor LT (LDLT) program. Critically ill patients with a Chronic Liver Failure Consortium (CLIF-C) ACLF score (CLIF-C_ACLF_score) ≥65, previously considered unsuitable for LT, were included to explore the excess mortality threshold of the CLIF-C_ACLF_score (CLIF-C_ACLF_score_threshold). We followed 854 consecutive patients with ACLF (276 ACLF grade 2 and 215 ACLF grade 3) over 10 years among 4432 LT recipients between 2008 and 2019. For advanced ACLF patients without immediate deceased-donor (DD) allocation, an urgent LDLT program was expedited. The CLIF-C_ACLF_score_threshold was determined by the metrics of transplant survival benefit: >60% 1-year and >50% 5-year survival rate. In predicting post-LT mortality, the CLIF-C_ACLF_score outperformed the (model for end-stage liver disease-sodium) MELD-Na and (model for end-stage liver disease) MELD-3.0 scores but was comparable to the Sundaram ACLF-LT-mortality score. A CLIF-C_ACLF_score ≥65 (n = 54) demonstrated posttransplant survival benefits, with 1-year and 5-year survival rates of 66.7% and 50.4% (P < .001), respectively. Novel CLIF-C_ACLF_score_threshold for 1-year and 5-year mortalities was 70 and 69, respectively. A CLIF-C_ACLF_score-based nomogram for predicting survival probabilities, integrating cardiovascular disease, diabetes, and donor type (LDLT vs DDLT), was generated. This study suggests reconsidering the criteria for unsuitable LT with a CLIF-C_ACLF_score ≥65. Implementing a timely salvage LT strategy, and incorporating urgent LDLT, can enhance survival rates.

Recommendations on Robotic Hepato-Pancreato-Biliary Surgery. The Paris Jury-Based Consensus Conference

OBJECTIVE

To establish the first consensus guidelines on the safety and indications of robotics in Hepato-Pancreatic-Biliary (HPB) surgery. The secondary aim was to identify priorities for future research.

BACKGROUND

HPB robotic surgery is reaching the IDEAL 2b exploration phase for innovative technology. An objective assessment endorsed by the HPB community is timely and needed.

METHODS

The ROBOT4HPB conference developed consensus guidelines using the Zurich-Danish model. An impartial and multidisciplinary jury produced unbiased guidelines based on the work of 10 expert panels answering predefined key questions and considering the best-quality evidence retrieved after a systematic review. The recommendations conformed with the GRADE and SIGN50 methodologies.

RESULTS

Sixty-four experts from 20 countries considered 285 studies, and the conference included an audience of 220 attendees. The jury (n=10) produced recommendations or statements covering 5 sections of robotic HPB surgery: technology, training and expertise, outcome assessment, and liver and pancreatic procedures. The recommendations supported the feasibility of robotics for most HPB procedures and its potential value in extending minimally invasive indications, emphasizing, however, the importance of expertise to ensure safety. The concept of expertise was defined broadly, encompassing requirements for credentialing HPB robotics at a given center. The jury prioritized relevant questions for future trials and emphasized the need for prospective registries, including validated outcome metrics for the forthcoming assessment of HPB robotics.

CONCLUSIONS

The ROBOT4HPB consensus represents a collaborative and multidisciplinary initiative, defining state-of-the-art expertise in HPB robotics procedures. It produced the first guidelines to encourage their safe use and promotion.

Dynamic changes of serum α-fetoprotein predict the prognosis of bevacizumab plus immunotherapy in hepatocellular carcinoma

BACKGROUND

Alpha-fetoprotein (AFP) has been established as a biomarker for hepatocellular carcinoma (HCC); however, whether its dynamic changes could predict the response to systemic therapy remains elusive. This study explored the AFP trajectory and the association with survival in patients who received bevacizumab plus immunotherapy.

MATERIALS AND METHODS

We retrospectively enrolled 536 HCC patients who received bevacizumab plus immunotherapy between February 2021 and February 2023. Patients were divided into two groups according to AFP values before treatment (400 ng/ml). Dynamic changes of AFP were fitted using a latent class model to generate the AFP trajectories. Multivariable Cox models were utilized to compute hazard ratios (HRs) for survival. Inverse-probability-of-treatment weighted analyses were conducted to mitigate the influence of unmeasured confounding variables. The primary endpoint is progression-free survival (PFS). The second endpoint is overall survival (OS).

RESULTS

Three distinct trajectories were identified for AFP-low and AFP-high patients, respectively. In the AFP-low group, compared with the high-rising class (25%; n =69), HRs of PFS were 0.39 and 0.2 for the low-stable class (59.1%; n =163) and sharp-falling class (15.9%; n =44), after adjusting by tumor diameter, tumor number, and extra-hepatic metastasis. In the AFP-high group, compared with the high-stable class (18.5%; n =48), HRs of PFS were 0.3 and 0.04 for the middle-stable class (56.5%; n =147) and sharp-falling class (25%; n =65), after adjusting by tumor diameter, tumor number, and extra-hepatic metastasis. Furthermore, the AFP trajectories exhibited the utmost relative importance among all covariates regarding PFS and OS in the multivariable regression models.

CONCLUSION

The AFP trajectories in HCC patients receiving bevacizumab and immunotherapy constituted an independent biomarker indicative of clinical outcomes. Findings from this study hold potential clinical utility in dynamically forecasting the prognosis of systemic therapy in HCC patients and facilitating clinical decision-making. Rapid reduction of AFP post-treatment can lead to favorable patient prognoses.

[A 2024 inventory in oncology news]

The editorial board of the Bulletin du cancer has compiled a summary of the news from 2024 in oncology, based on the main results presented at international congresses or published over the past year. After a year marked by the success of the Olympic Games, the selection of data is presented and discussed in podiums of three main results by topic. Emphasis is placed on studies that have an immediate impact on practice and on data that raise important questions for the year 2025.

Gut-liver translocation of pathogen Klebsiella pneumoniae promotes hepatocellular carcinoma in mice

Hepatocellular carcinoma (HCC) is accompanied by an altered gut microbiota but whether the latter contributes to carcinogenesis is unclear. Here we show that faecal microbiota transplantation (FMT) using stool samples from patients with HCC spontaneously initiate liver inflammation, fibrosis and dysplasia in wild-type mice, and accelerate disease progression in a mouse model of HCC. We find that HCC-FMT results in gut barrier injury and translocation of live bacteria to the liver. Metagenomic analyses and bacterial culture of liver tissues reveal enrichment of the gut pathogen Klebsiella pneumoniae in patients with HCC and mice transplanted with the HCC microbiota. Moreover, K. pneumoniae monocolonization recapitulates the effect of HCC-FMT in promoting liver inflammation and hepatocarcinogenesis. Mechanistically, K. pneumoniae surface protein PBP1B interacts with and activates TLR4 on HCC cells, leading to increased cell proliferation and activation of oncogenic signalling. Targeting gut colonization using K. oxytoca or TLR4 inhibition represses K. pneumoniae-induced HCC progression. These findings indicate a role for an altered gut microbiota in hepatocarcinogenesis.

Construction and validation of a machine learning-based prediction model for short-term mortality in critically ill patients with liver cirrhosis

OBJECTIVE

Critically ill patients with liver cirrhosis generally have a poor prognosis due to complications such as multiple organ failure. This study aims to develop a machine learning-based prediction model to forecast short-term mortality in critically ill cirrhotic patients in the intensive care unit (ICU), thereby assisting clinical decision-making for intervention and treatment.

METHODS

Machine learning models were developed using clinical data from critically ill cirrhotic patients in the MIMIC database, with multicenter validation performed using data from the eICU database and Qinghai University Affiliated Hospital(QUAH). Various machine learning models, including a Stacking ensemble model, were employed, with the SHAP method used to enhance model interpretability.

RESULTS

The Stacking ensemble model demonstrated superior predictive performance through internal and external validation, with AUC and AP values surpassing those of individual algorithms. The AUC values were 0.845 in the internal validation set, 0.819 in the eICU external validation, and 0.761 in the QUAH validation set. Additionally, the SHAP method highlighted key prognostic variables such as INR, bilirubin, and urine output. The model was ultimately deployed as a web-based calculator for bedside decision-making.

CONCLUSION

The machine learning model effectively predicts short-term mortality risk in critically ill cirrhotic patients in the ICU, showing strong predictive performance and generalizability. The model's robust interpretability and its deployment as a web-based calculator suggest its potential as a valuable tool for assessing the prognosis of cirrhotic patients.

Comparison of the Effectiveness of Transarterial Bland Embolization and Transarterial Chemoembolization for Intermediate-Stage Hepatocellular Carcinoma: A Propensity Score-Matched Study of 1,008 Patients

PURPOSE

To assess the effectiveness of transarterial bland embolization (TAE) compared with transarterial chemoembolization (TACE) therapy in the treatment of patients with intermediate-stage hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Two thousand two hundred ninety-seven patients with intermediate-stage HCC were screened, and 1,461 patients who underwent TAE or TACE as the first-choice treatment were retrospectively analyzed and baseline matched according to the 2 treatment methods. Subgroup analysis was performed among patients according to the Up-to-7 criteria. The primary endpoint was overall survival (OS).

RESULTS

A total of 1,461 patients with HCC who underwent TAE or TACE were included; 730 patients underwent TACE and 731 underwent TAE. The patients in the TAE group exhibited poorer liver function and a significantly higher rate of hepatitis B infection (P < .001) compared with the TACE group. After propensity score matching, 504 well-matched pairs of patients with intermediate-stage HCC were selected for analysis. Univariate analysis showed that TACE significantly prolonged patient survival compared with TAE (P < .001). The 1-, 2-, and 3-year OS rates were 74.3%, 57.1%, and 44.4% and for the TACE group and 58.3%, 32.4%, and 21.7% for the TAE group, respectively. Multivariate analysis showed a hazard ratio of 0.517 (95% CI, 0.442-0.605; P < .001) for the TACE approach over the TAE approach for OS. The TACE group had a significantly higher overall response rate than the TAE group (35% vs 26%; P = .024).

CONCLUSIONS

TACE resulted in higher response rate and longer OS compared with TAE as the initial treatment for intermediate-stage HCC.

Transjugular intrahepatic portosystemic shunt for the patients on the liver transplant list

Patients with cirrhosis-associated and portal hypertension-associated complications may benefit from TIPS and/or liver transplantation. In many patients, the decision of whether or not TIPS should be placed prior to liver transplantation is fairly clear-cut. Nevertheless, there are some patients in whom the decision can be more complex. On one hand, TIPS is easily available in contrast to liver transplantation, and patients with TIPS may have clinical improvement. On the other hand, although TIPS may improve the situation of the patient, this improvement may not be sufficient to significantly improve the quality of life. Furthermore, TIPS malposition may be challenging for liver transplantation surgery. This review approaches the advantages and disadvantages of TIPS placement in patients who are candidates for liver transplantation and proposes decision pathways for patients with complications of portal hypertension on the liver transplant waiting list.

Effect of donor warm ischemia time during graft extraction in right lobe robotic donor hepatectomy on recipient outcomes-A propensity score matched analysis

One of the concerns specific to minimally invasive donor hepatectomy (MIDH) is the prolonged time required for graft extraction after completion of the donor hepatectomy (donor warm ischemia time [DWIT]). There has never been an objective evaluation of minimally invasive donor hepatectomy-DWIT on allograft function in living donor liver transplantation. We evaluated the effect of DWIT following robotic donor hepatectomy (RDH) on recipient outcomes and compared them with a matched cohort of open donor hepatectomy (ODH). Demographic, perioperative, and recipient's postoperative outcome data for all right lobe (RL)-RDH performed between September 2019 and July 2023 were analyzed and compared with a propensity score matched cohort (1:1) of RL-ODH from the same time period. Of a total of 103 RL-RDH and 446 RL-ODH, unmatched and propensity score matched analysis (1:1) revealed a significantly longer DWIT in the RDH group as compared to the ODH group (9.33 ± 3.95 vs 2.87 ± 2.13, P < .0001). This did not translate into any difference in the rates of early allograft dysfunction (EAD), biliary complications, major morbidity, or overall 1-and 3-month survival. The receiver operating characteristic curve analysis threshold for DWIT-early allograft dysfunction was 9 minutes (area under receiver operating characteristic: 0.67, sensitivity = 80%, specificity = 53.8%). We show that prolonged DWIT within an acceptable range in RDH does not have deleterious effects on short-term recipient outcomes. Further long-term studies are required to confirm our findings, especially with regard to nonanastomotic biliary complications.

Technical Note on Modified Direct Intrahepatic Portocaval Shunt Targeting Different Vessels for Portal Vein Obstruction in Cirrhosis

PURPOSE

This study aimed to explore a modified direct intrahepatic portocaval shunt (DIPS) technique as an alternative approach for patients with portal vein occlusion (PVO) and cirrhosis who were not candidates for traditional transjugular intrahepatic portosystemic shunt (TIPS) due to anatomical challenges.

TECHNIQUE

Three patients with esophageal or gastric fundus variceal hemorrhage complicated by severe PVO were treated using innovative DIPS approaches. Preoperative contrast-enhanced computed tomography was employed to assess anatomical feasibility. The modified DIPS techniques involved targeting dilated varicose veins or the confluence of the superior mesenteric and splenic veins to access the inferior vena cava. For broader clinical applications, we outlined the anatomical conditions necessary for adopting the method proposed in this study. Following the puncture, portal hypertension was effectively alleviated, and bleeding was controlled. There were no obvious complications during the follow-up period.

CONCLUSION

Modified DIPS targeting different vessels appears to be a feasible alternative for the treatment of severe PVO when conventional TIPS by ultrasound-guided percutaneous transhepatic or transsplenic pathway and DIPS are unsuccessful. Future validation in a larger patient population is needed.

LEVEL OF EVIDENCE

Level 4, Case Series.

Recipient blood group does not affect hepatocellular carcinoma recurrence after living donor liver transplantation in Korea

PURPOSE

This study assessed whether or not the ABO blood type affects the incidence of HCC recurrence after living donor liver transplantation (LDLT).

METHODS

This retrospective observational study included 856 patients with hepatocellular carcinoma (HCC) who underwent LDLT between January 2006 and December 2016 at the Asan Medical Center.

RESULTS

This study included 324 patients (37.9%) with blood type A, 215 (25.1%) with blood type B, 210 (24.5%) with blood type O, and 107 (12.5%) with blood type AB. ABO-incompatible LT was performed in 136 (15.9%) patients. The independent risk factors for the disease-free survival (DFS) were maximal tumor diameter, microvascular invasion, and Milan criteria. The only independent risk factor for the overall survival (OS) was microvascular invasion. The ABO blood group did not affect the DFS (P = 0.978) or OS (P = 0.261). The DFS according to the ABO blood group did not differ significantly between the ABO-compatible (p = 0.701) and ABO-incompatible LDLT recipients (p = 0.147). The DFS according to the ABO blood group did not differ significantly between patients within the Milan criteria (p = 0.934) and beyond the Milan criteria (p = 0.525). The DFS did not differ significantly between recipients with and without type A blood (p = 0.941).

CONCLUSIONS

This study demonstrated that the ABO blood group system had no prognostic impact on the oncological outcomes of patients undergoing LT for HCC.

Artificial Liver Support Systems in Acute Liver Failure and Acute-on-Chronic Liver Failure: Systematic Review and Meta-Analysis

OBJECTIVES

To systematically review the safety and efficacy of nonbiological (NBAL) or biological artificial liver support systems (BAL) and whole-organ extracorporeal liver perfusion (W-ECLP) systems, in adults with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF).

DATA SOURCES

Eligible NBAL/BAL studies from PubMed/Embase searches were randomized controlled trials (RCTs) in adult patients with ALF/ACLF, greater than or equal to ten patients per group, reporting outcomes related to survival, adverse events, transplantation rate, and hepatic encephalopathy, and published in English from January 2000 to July 2023. Separately, we searched for studies evaluating W-ECLP in adult patients with ALF or ACLF published between January1990 and July 2023.

STUDY SELECTION AND DATA EXTRACTION

Two researchers independently screened citations for eligibility and, of eligible studies, retrieved data related to study characteristics, patients and interventions, outcomes definition, and intervention effects. The Cochrane Risk of Bias 2 tool and Joanna Briggs Institute checklists were used to assess individual study risk of bias. Meta-analysis of mortality at 28-30 days post-support system initiation and frequency of at least one serious adverse event (SAE) generated pooled risk ratios (RRs), based on random (mortality) or fixed (SAE) effects models.

DATA SYNTHESIS

Of 17 trials evaluating NBAL/BAL systems, 11 reported 28-30 days mortality and five reported frequency of at least one SAE. Overall, NBAL/BAL was not statistically associated with mortality at 28-30 days (RR, 0.85; 95% CI, 0.67-1.07; p = 0.169) or frequency of at least one SAE (RR, 1.15; 95% CI, 0.99-1.33; p = 0.059), compared with standard medical treatment. Subgroup results on ALF patients suggest possible benefit for mortality (RR, 0.67; 95% CI, 0.44-1.03; p = 0.069). From six reports of W-ECLP (12 patients), more than half (58%) of severe patients were bridged to transplantation and survived without transmission of porcine retroviruses.

CONCLUSIONS

Despite no significant pooled effects of NBAL/BAL devices, the available evidence calls for further research and development of extracorporeal liver support systems, with larger RCTs and optimization of patient selection, perfusion durability, and treatment protocols.

Impact of tacrolimus on interferon gamma ELISpot assay results for the assessment of T-cell immunity: Proof-of-concept

SOT patients require immunosuppressors to avoid graft rejection. Therapeutic drug monitoring is insufficient to find the optimal balance with immunosuppression. The evaluation of cell-mediated immunity by enzyme-linked immunospot (ELISpot) assay enumerating interferon-gamma (IFN-γ) is increasingly use. ELISpot assays are performed on peripheral blood mononuclear cells (PBMC) isolated from blood and brought into contact with specific peptides in an immunosuppressor-free environment. This study aims to determine the in vitro diffusion of tacrolimus in PBMC and to assess whether prior in vitro incubation of PBMC with tacrolimus modifies the IFN-γ ELISpot results when assessing the T-cell immune response. PBMC from healthy volunteers were obtained. Tacrolimus was added to the ELISpot wells at increasing concentration and quantification was obtained using liquid chromatography mass spectrometry. Results showed that the in vitro PBMC diffusion rate of tacrolimus was measured at 32%. A decrease in T-cell reactivity occurred with increasing tacrolimus concentration. The intra-PBMC concentration of tacrolimus able to inhibit 50% of T-cell reactivity was 163 pg/106 PBMC, which is in the range of the in vivo intra-PBMC concentration in SOT recipients. T-cell functional assessment using ELISpot in patients treated with immunosuppressors may require the addition of immunosuppressors in vitro to better reflect the in vivo situation.

Crucial Role of c-Myc/Monocarboxylate Transporter 4 Signaling in Capsaicin Induced Apoptotic and Anti-Warburg Effects in Hepatocellular Carcinoma

Though Capsaicin from chili peppers was known to have antitumor effects in several cancers, the underlying antitumor pathogenesis of Capsaicin is not clear to date. Thus, the antitumor mechanism of Capsaicin was explored in Hep3B and Huh7 hepatocellular carcinoma (HCC) cells in relation to c-Myc/monocarboxylate transporter 4 (MCT4) signaling. To elucidate the antitumor mechanism of capsaicin, cytotoxicity assay, cell cycle analysis, Western blotting, RT-qPCR, RNA interference, ELISA, immunoprecipitation, and mouse xenograft model were used in this work. Capsaicin increased the cytotoxicity, subG1 population, and the number of TUNEL-positive bodies in Huh7 and Hep3B cells. Consistently, Capsaicin diminished the expression of pro-PARP, HK2, PKM2, LDHA, glucose transporter type 1 (Glut1), c-Myc, and monocarboxylate transporter 4 (MCT4) in Huh7 and Hep3B cells, along with decreased production of glucose, lactate, and ATP. However, a glycolysis end product pyruvate treatment reversed the capacity of Capsaicin to attenuate the expression of pro-PARP, HK2, c-Myc, and MCT4 in Hep3B cells. Furthermore, Capsaicin reduced c-Myc stability in the presence of cycloheximide and induced c-Myc ubiquitination in Hep3B cells, while c-Myc directly binds to MCT4 as a lactate transporter and downstream of c-Myc in Hep3B cells by immunoprecipitation and correlation factor (Spearman efficient = 0.0027). Furthermore, a preliminary analysis of an animal study reveals that Capsaicin significantly suppressed the growth of Hep3B cells inoculated in BALB/c nude mice without hurting body weight, liver, and spleen. Our findings provide novel evidence that Capsaicin exerts apoptotic and anti-Warburg effect via c-Myc/MCT4 signaling axis as a potent anticancer candidate for liver cancer therapy.

Correlation of Needle Biopsy-Acquired Histopathologic Grade of Hepatocellular Carcinoma with Outcomes after Thermal Ablation

PURPOSE

To correlate preablation needle biopsy-acquired histopathologic grade of Liver Imaging Reporting and Data System (LI-RADS) 5 hepatocellular carcinoma (HCC) with postablation local tumor control rate, intrahepatic distant tumor progression-free survival, and overall survival.

MATERIALS AND METHODS

This single-center, retrospective cohort study included adult patients with LI-RADS 5 HCC who underwent a preablation core needle biopsy within 3 months prior to thermal ablation from January 2015 to December 2022. Histopathologic grade from the needle biopsy was evaluated as predictor of local tumor control rate, intrahepatic distant tumor progression-free survival, and overall survival. Kaplan-Meier survival curves were compared using the Gehan generalized Wilcoxon test.

RESULTS

The study group comprised 133 patients (mean age, 67 years [SD ± 10]; 107 men) with LI-RADS 5 confirmed HCC, stratified into 18 poorly differentiated tumors (median follow-up, 27.7 months; interquartile range [IQR], 15.5-55.4 months) and 115 well-differentiated/moderately differentiated tumors (median follow-up, 29.2 months; IQR, 15.4-59.9 months). No difference in local tumor control rate was noted between the 2 cohorts (hazard ratio [HR], 1.16; 95% CI, 0.32-4.23; P = .898). There was significantly lower intrahepatic distant tumor progression-free survival after thermal ablation in the poorly differentiated cohort (HR, 2.54; 95% CI, 0.92-7.05; P < .001). The overall survival in the poorly differentiated cohort was also lower, although this did not reach statistical significance (HR, 1.77; 95% CI, 0.60-5.26; P = .202).

CONCLUSIONS

Patients with needle biopsy-proven poorly differentiated LI-RADS 5 HCC had significantly lower intrahepatic distant tumor progression-free survival after thermal ablation compared with those with well-differentiated/moderately differentiated HCC.

Prediction of the Intra-T Lymphocyte Tacrolimus Concentration after Kidney Transplantation with Population Pharmacokinetic Modeling

The intracellular tacrolimus concentration in CD3+ T lymphocytes is proposed to be a better representative of the active component of tacrolimus than the whole blood concentration. However, intracellular measurements are complicated. Therefore, the aim of this study was to describe the relationship between intracellular and whole blood tacrolimus concentrations in a population pharmacokinetic model. Twenty-eight de novo kidney transplant recipients, treated with a once-daily oral extended-release tacrolimus formulation, were followed during the first-month post-transplantation. Additional whole blood and intracellular tacrolimus concentrations were measured at day 6 ± 1 (pre-dose, 4 and 8 hours post-dose) and day 14 ± 3 (pre-dose) post-transplantation. Pharmacokinetic analysis was performed using nonlinear mixed effects modeling software (NONMEM). The ratio between intracellular (n = 109) and whole blood (n = 248) concentrations was best described by a two-compartment whole blood model with an additional intracellular compartment without mass transfer from the central compartment. The ratio remained stable over time. Prednisolone dose influenced the absorption rate of tacrolimus, while hemoglobin, CYP3A4*22 allele carrier, and CYP3A5 expresser status were associated with the oral clearance of tacrolimus (P-value < 0.001). Furthermore, the intracellular tacrolimus concentrations were correlated with the intracellular production of interleukin-2 (P-value 0.015). The intracellular tacrolimus concentration can be predicted from a measured whole blood concentration using this model, without the need for repeated intracellular measurements. This knowledge is particularly important when the intracellular concentration is ready to be implemented into clinical practice, to overcome the complexities of cell isolation and analytical methods.

Are there any benefits of prolonged hypothermic oxygenated perfusion?: Results from a national retrospective study

Dual hypothermic oxygenated perfusion (DHOPE) is increasingly being used to extend liver preservation to improve transplant logistics. However, little is known about its benefits in high-risk liver grafts. This study aimed to investigate whether prolonged DHOPE provides benefits other than improved logistics in all liver types. We performed a national retrospective cohort study of 177 liver transplants from 12 Italian centers preserved with DHOPE for ≥4 hours between 2015 and 2022. A control group of 177 DHOPEs of <4 hours during the same period was created using 1:1 propensity score matching. The impact of risk profiles and preservation times on the outcomes was assessed using univariable and multivariable regression models. No significant differences in posttransplant outcomes were found between prolonged and short DHOPEs. However, the prolonged group had a significantly lower incidence of posttransplant acute kidney injury (AKI) compared to the short group (30.5% vs. 44.6%, p = 0.008). Among prolonged DHOPEs, no differences in transplant outcomes were observed according to donor risk index, Eurotransplant definition for marginal grafts, and balance of risk score. DHOPE duration was associated with a lower risk of AKI in multivariable models adjusted for donor risk index, Eutrotransplant marginal grafts, and balance of risk score. Prolonged hypothermic oxygenated perfusion confirmed its protective effect against AKI in a multivariable model adjusted for donor and recipient risk factors [OR: 0.412, 95% CI: 0.200-0.850, p = 0.016]. Prolonged DHOPE is widely used to improve transplant logistics, provides good results with high-risk grafts, and appears to be associated with a lower risk of posttransplant AKI. These results provide further insight into the important role of DHOPE in preventing posttransplant complications.

Advancing immunosuppression in liver transplantation: the role of regulatory T cells in immune modulation and graft tolerance

Prolonged immunosuppressive therapy in liver transplantation (LT) is associated with significant adverse effects, such as nephrotoxicity, metabolic complications, and heightened risk of infection or malignancy. Regulatory T cells (Tregs) represent a promising target for inducing immune tolerance in LT, with the potential to reduce or eliminate the need for life-long immunosuppression. This review summarizes current knowledge on the roles of Tregs in LT, highlighting their mechanisms and the impact of various immunosuppressive agents on Treg stability and function. The liver's distinct immunological microenvironment, characterized by tolerogenic antigen-presenting cells and high levels of interleukin (IL)-10 and transforming growth factor-β, positions this organ as an ideal setting for Treg-mediated tolerance. We discuss Treg dynamics in LT, their association with rejection risk, and their utility as biomarkers of transplant outcomes. Emerging strategies, including the use of low-dose calcineurin inhibitors with mammalian target of rapamycin inhibitors, adoptive Treg therapy, and low-dose IL-2, aim to enhance Treg function while providing sufficient immunosuppression. Thus, the future of LT involves precision medicine approaches that integrate Treg monitoring with tailored immunosuppressive protocols to optimize long-term outcomes for LT recipients.

Role of Coagulation Factors in Hepatocellular Carcinoma: A Literature Review

Hepatocyte carcinoma (HCC) is a globally prevalent neoplasm with profound effects on morbidity and mortality rates. This review summarizes the complex interactions between coagulation abnormalities and the pathophysiological mechanisms underlying HCC. Essential coagulation biomarkers, such as P-selectin, thrombomodulin, d-dimer, prothrombin, and von Willebrand factor, are reviewed for their diagnostic, prognostic, and therapeutic significance. The contribution of these biomarkers to tumor progression, metastatic spread, and patient prognosis is highlighted through a synthesis of contemporary research findings. In addition, this review highlights the underlying mechanisms linking coagulation pathways to HCC pathogenesis and explores potential therapeutic targets. An integrative perspective on the role of coagulation markers in HCC may improve clinical management strategies for patients affected by this malignancy.

Are Ki-67 and Procalcitonin Expression Levels Useful in Predicting the Biological Behavior of Hepatocellular Carcinoma After Liver Transplantation?

Background: Examinations of procalcitonin (PCT) and Ki-67 expression levels in hepatocellular carcinoma (HCC) patients who have undergone liver transplantation (LT) through immunohistochemical analyses of tumor tissue may reveal the biological characteristics of the tumor, thus informing the selection of HCC patients for LT. Methods: Hepatectomy specimens from 86 HCC patients who underwent LT were obtained and analyzed immunohistochemically for the expression of PCT and Ki-67. The percentage and intensity of PCT staining, as well as the percentage of Ki-67 expression, were assessed for each patient. The impacts of PCT and Ki-67 expression on disease-free survival, overall survival, and the recurrence rate were studied, as well as their correlations with other clinicopathological features. Results: The recurrent HCC group showed a higher Ki-67 level (p < 0.001), larger maximum dominant tumor diameter (p < 0.001), and higher rate of vascular invasion (p = 0.001). The pre-transplant AFP (p = 0.001), maximum dominant tumor diameter (p < 0.001), number of tumor nodules (p < 0.001), rate of vascular invasion (p = 0.001), and Ki-67 level (p = 0.044) were higher in patients beyond the Milan criteria. Similarly, the pre-transplant AFP (p < 0.001); maximum dominant tumor diameter (p < 0.001); number of tumor nodules (p < 0.001); rates of portal vein tumor thrombus (p = 0.002), poor differentiation (p = 0.021), and vascular invasion (p < 0.001); and Ki-67 level (p = 0.010) were higher in patients beyond the expanded Malatya criteria. The maximum dominant tumor diameter (p = 0.006); Ki-67 level (p = 0.003); rates of vascular invasion (p < 0.001), cases beyond the Milan criteria (p = 0.042) and the expanded Malatya criteria (p = 0.027), and portal vein tumor thrombus (p = 0.020); and presence of recurrence (p < 0.001) were higher in HCC patients with mortality. The Kaplan-Meier estimates indicated that Ki-67 levels exceeding 5% significantly affected DFS and OS. Although the Kaplan-Meier estimates indicated that a PCT staining percentage of ≥25% did not have a statistically significant effect on DFS or OS, the outcomes may be considered clinically significant. Conclusions: This study demonstrated that the Ki-67 proliferation index can be used as a predictive biomarker of the biological behavior of HCC. Furthermore, we claim that PCT expression over a particular threshold might impact recurrence and survival, and we believe that further multicenter prospective studies focused on standardized PCT antibody staining are crucial in order to determine its potential as a biomarker for HCC.

Benefits of Liver Volume and Serum Zinc Level Assessment for the Screening of Covert Hepatic Encephalopathy in Patients with Child-Pugh Class A Cirrhosis

Background/Objectives: Covert hepatic encephalopathy (CHE) is associated with decreased quality of life. Detection of Child-Pugh class A is necessary for its early diagnosis. This study aimed to establish a simple diagnostic method of CHE in patients with Child-Pugh class A. Methods: One hundred patients with liver cirrhosis without overt hepatic encephalopathy and sixty-eight with liver cirrhosis and Child-Pugh class A who visited our institution were enrolled. CHE was diagnosed using number connection test B in the neuropsychiatric test (NPT). Clinical data were compared. Results: The liver volume/body surface area ratio (LV/BSA) was associated with CHE in patients with all-cause and Child-Pugh class A liver cirrhosis. Multiple logistic regression analysis revealed that low LV/BSA and low serum zinc (Zn) levels were significantly associated with CHE in Child-Pugh class A liver cirrhosis. The best cutoff values in the receiver operating characteristic curve analysis showed that the complication rate of CHE was 54.8% in patients with LV/BSA < 620 mL/m2, which was 2.9 times higher than that in patients with larger liver volume. Referring to the cutoff values for LV/BSA and Zn (<70 µg/dL), in cases with LV/BSA < 620 mL/m2 and Zn < 70 µg/dL, 64.2% had CHE, whereas in cases with LV/BSA ≥ 620 mL/m2 and Zn ≥ 70 µg/dL, 94.5% did not have CHE. Conclusions: Liver volume can be used as a risk assessment tool for CHE. LV/BSA and serum Zn levels are considered effective diagnostic tools for CHE, serving as alternatives to NPT in patients with Child-Pugh class A liver cirrhosis.

Impact of immunosuppressants on tumor pulmonary metastasis: new insight into transplantation for hepatocellular carcinoma

Pulmonary metastasis is a life-threatening complication for patients with hepatocellular carcinoma (HCC) undergoing liver transplantation (LT). In addition to the common mechanisms underlying tumor metastasis, another inevitable factor is that the application of immunosuppressive agents, including calcineurin inhibitors (CNIs) and rapamycin inhibitors (mTORis), after transplantation could influence tumor recurrence and metastasis. In recent years, several studies have reported that mTORis, unlike CNIs, have the capacity to modulate the tumorigenic landscape post-liver transplantation by targeting metastasis-initiating cells and reshaping the pulmonary microenvironment. Therefore, we focused on the effects of immunosuppressive agents on the lung metastatic microenvironment and how mTORis impact tumor growth in distant organs. This revelation has provided profound insights into transplant oncology, leading to a renewed understanding of the use of immunosuppressants after LT for HCC.

AIRE mutation in an elderly Caroli's patient with cholangitis and sepsis: a case report

BACKGROUND

Caroli's disease, an autosomal recessive, hereditary-related disorder, is a rare disease, in which the diagnosis is based primarily on medical imaging and pathophysiological examinations. It is characterized by intrahepatic cystic dilation or cysts. Hepatic resection of diseased lobes can cure or avoid the risk of malignancy.

CASE PRESENTATION

A 65-year-old Asian man was admitted to our hospital with cholangitis and recurrent septicemia. The pathological diagnosis was polycystic bile duct dilation and cholangitis, consistent with the symptoms of Caroli's disease. In addition, a genetic test report indicated that the autoimmune regulator (AIRE) gene had a c.275G > A variant (p. Arg92Gln hybrid mutation), which was different from the previously reported PKHD1 gene mutation in Caroli's disease.

CONCLUSION

This finding suggests that AIRE mutations may be associated with Caroli's disease, with a risk of death and difficulty in curing.

Laparoscopic and robotic hepatectomy in living liver donors. Current state and prospects

Minimally invasive living-donor hepatectomy is a relatively new surgical technique that can improve donor safety and expedite donor rehabilitation. Following an early stage of research where donor safety was not adequately established, the minimally invasive approach nowadays yields better outcomes when carried out by experienced surgeons. Important factors include donor selection criteria, hospital equipment, and surgeon’s learning curve. This review describes the current status of laparoscopic and robotic living-donor hepatectomy, along with the challenges facing the advancement of these surgical techniques.

Etiology-Dependent Microbiome Differences in Hepatocellular Carcinoma Development

Chronic liver disease is characterised by persistent inflammation, tissue damage, and regeneration, which leads to steatosis, fibrosis, and, lastly, cirrhosis and hepatocellular carcinoma (HCC). HCC, the most prevalent form of primary liver cancer, is one of the leading causes of cancer-related mortality worldwide. The gut microbiota plays a fundamental role in human physiology, and disturbances in its critical balance are widely recognised as contributors to various pathological conditions, including chronic liver diseases, both infectious and non-infectious in nature. Growing interest in microbiota research has recently shifted the focus towards the study of intratumoural microbiota, referred to as the "oncobiome", which can significantly impact the development and progression of HCC. In this review, we discuss existing research and provide an overview of the microbiota influence on viral hepatitis, particularly in shaping the progression of liver disease caused by the hepatitis B and hepatitis C viruses. We also explore microbial dysbiosis and its contribution to the silent and dangerous progression of non-alcoholic fatty liver disease. Additionally, we address the impact of alcohol on the liver and its interaction with the microbiota, tracing the pathway from inflammation to cirrhosis and cancer. The review emphasises the most common etiologies of hepatocellular carcinoma.

Systematic Analysis of Disulfidptosis-Related lncRNAs in Hepatocellular Carcinoma with Vascular Invasion Revealed That AC131009.1 Can Promote HCC Invasion and Metastasis through Epithelial-Mesenchymal Transition

Disulfidptosis, a recently identified pathway of cellular demise, served as the focal point of this research, aiming to pinpoint relevant lncRNAs that differentiate between hepatocellular carcinoma (HCC) with and without vascular invasion while also forecasting survival rates and responses to immunotherapy in patients with vascular invasion (VI+). First, we identified 300 DRLRs in the TCGA database. Subsequently, utilizing univariate analysis, LASSO-Cox proportional hazards modeling, and multivariate analytical approaches, we selected three DRLRs (AC009779.2, AC131009.1, and LUCAT1) with the highest prognostic value to construct a prognostic risk model for VI+ HCC patients. Multivariate Cox regression analysis revealed that this model is an independent prognostic factor for predicting overall survival that outperforms traditional clinicopathological factors. Pathway analysis demonstrated the enrichment of tumor and immune-related pathways in the high-risk group. Immune landscape analysis revealed that immune cell infiltration degrees and immune functions had significant differences. Additionally, we identified valuable chemical drugs (AZD4547, BMS-536924, BPD-00008900, dasatinib, and YK-4-279) for high-risk VI+ HCC patients. In-depth bioinformatics analysis was subsequently conducted to assess immune characteristics, drug susceptibility, and potential biological pathways involving the three hub DRLRs. Furthermore, the abnormally elevated transcriptional levels of the three DRLRs in HCC cell lines were validated through qRT-PCR. Functional cell assays revealed that silencing the expression of lncRNA AC131009.1 can inhibit the migratory and invasive capabilities of HCC cells, a finding further corroborated by the chorioallantoic membrane (CAM) assay. Immunohistochemical analysis and hematoxylin-eosin staining (HE) staining provided preliminary evidence that AC131009.1 may promote the invasion and metastasis of HCC cells by inducing epithelial-mesenchymal transition (EMT) in both subcutaneous xenograft models and orthotopic HCC models within nude mice. To summarize, we developed a risk assessment model founded on DRLRs and explored the potential mechanisms by which hub DRLRs promote HCC invasion and metastasis.

Graft inflow modulation in recipients with portal hypertension

The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching, potentially leading to the "small-for-size syndrome" (SFSS). SFSS is a rare dysfunction that may affect a partial liver graft, characterized by coagulopathy, cholestasis, ascites, and encephalopathy. A key role in the physiopathology of SFSS is played by portal hypertension (PHT) to which a small allograft is submitted after reperfusion, resulting in sinusoidal congestion and hemorrhage. Portal overflow injures the liver directly through nutrient excess, endothelial activation, and sinusoidal shear stress, and indirectly through arterial vasoconstriction. Thus, SFSS prevention relies not only on increasing graft volume (implementing the use of larger grafts or auxiliary/dual liver transplantation), but also on the control of the increased portal vein pressure (PVP) and portal vein flow (PVF). To this aim, surgical graft inflow modulation techniques (GIM) such as splenic artery ligation (SAL), splenectomy and hemiportocaval shunts, can be considered when an imbalance between the PVP and the hepatic arterial flow (HAF) is acknowledged. However, such strategies have their pros and cons, and a deep knowledge of the indications and complications is needed. Furthermore, pharmacological modulation has also been proposed. This review is aimed to update available literature on the current knowledge and strategies for modulating portal vein flow in LDLT.

Oxymatrine attenuates chronic allograft rejection by modulating immune responses and inhibiting fibrosis

BACKGROUND

Chronic rejection (CR) is a significant obstacle to long-term allograft survival. Oxymatrine (OMT) is a prominent bioactive compound widely utilized in traditional Chinese medicine for the management of inflammatory disorders and it has considerable potential as a therapeutic candidate for the treatment of CR.

METHODS

Well-established major histocompatibility complex (MHC) class II mismatched B6 mice. C-H-2bm12-to-C57BL/6 mouse transplantation was used as a CR model. Hematoxylin and eosin (H&E) staining, immunohistochemistry, and Masson's trichrome staining were used to assess pathological changes in the grafts, and the percentages of immune cells were determined by flow cytometry. The effects of OMT on the regulation of CD4+ T cell differentiation and cytokine secretion were verified in vitro.

RESULTS

OMT effectively alleviated pathological graft damage, characterized by chronic changes in intimal lesions, vasculopathy, and fibrosis and significantly prolonged cardiac allograft survival. OMT exerted its immunomodulatory effects by inhibiting T helper 1 (Th1) and T helper 17 (Th17) cell differentiation while promoting Treg differentiation both in vivo and in vitro. Further studies revealed that OMT inhibited the phosphorylation of mammalian target of rapamycin (mTOR), which is a potential mechanism underlying its immunosuppressive effects. OMT also inhibited the activation of B cells and the production of donor-specific antibody (DSA). In addition, OMT effectively alleviated chronic changes in fibrosis in cardiac allografts, and these changes may be related to the inhibition of the transforming growth factor-β (TGF-β)-Smad 2/3 pathway.

CONCLUSIONS

OMT attenuated CR by modulating the immune response and inhibiting graft fibrosis. Further in-depth investigations of OMT may provide valuable insights into the development of novel therapeutic strategies for CR inhibition.

The Role of Lymphadenectomy in the Surgical Treatment of Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Background: Lymphadenectomy in the operative management of hepatocellular carcinoma (HCC) remains controversial, with no recommendation for routine practice. Our study aimed to assess the effects of lymphadenectomy in addition to hepatic resection (HR) compared to HR alone for adults with HCC. Methods: This systematic review was conducted according to PRISMA guidelines until March 2023, searching and selecting the relevant literature comparing lymph node dissection or sampling, combined with HR, and with no lymph node removal. Critical appraisal of the included studies was performed using the ROBINS-I tool. Fixed- or random-effect meta-analysis models were carried out, and inter-studies were assessed for heterogeneity. Results: Fourteen studies were selected during the screening process. Data from eight studies containing 32,041 HCC patients were included in the quantitative synthesis. In total, 12,694 patients underwent lymph node dissection (LND), either selectively for preoperatively diagnosed or intraoperatively suspected lymph node metastasis (LNM) or unselectively (i.e., regardless of suspected LNM). According to LN status, 1-, 3- and 5-year mortality rates were higher in the LNM group with respect to both clinically negative LN (OR 3.25, 95% CI 2.52-4.21; p < 0.001; OR 3.79, 95% CI 2.74-5.24; p < 0.001; OR 3.92, 95% CI 2.61-5.88; p < 0.001) and proven LN0 (OR 1.75, 95% CI 1.0-3.04; p = 0.05; OR 2.88, 95% CI 1.79-4.63; p < 0.001; OR 2.54, 95% CI 1.33-4.84; p < 0.001). Moreover, the summary estimates of two controlled trials showed no significant difference in overall survival between LND groups and those without LND for negative LN patients. Conclusions: Lymph node dissection does not appear to improve overall survival, according to the available literature; thus, this does not support its routine adoption as part of standard liver resection for HCC. A case-by-case decision remains advisable.

Risk factors for postoperative morbidity after ventral hernia repair in patients with liver cirrhosis. A single tertiary center cohort

<b>Introduction:</b> Ventral hernias are common among patients with liver cirrhosis.<b>Aim:</b> The aim of our work was to evaluate potential risk factors for major postoperative morbidity after ventral hernia repair in cirrhotic patients.<b>Material and methods:</b> A retrospective cohort study was performed in 45 consecutive cirrhotic patients that underwent ventral hernia repair between 2005 and 2022. Major morbidity was defined as Clavien-Dindo ≥ IIIa at 30 days postoperatively. Uni- and multivariate analysis was performed to identify risk factors for major postoperative complications.<b>Results:</b> In our cohort, we observed an overall postoperative 30-day morbidity rate of 53.33% (n = 24), with 40% (n = 18) of cases classified as Clavien-Dindo IIIa or above. Elevated serum creatinine level preoperatively was identified as a statistically significant risk factor, both in the uni- as well as the multivariate analysis for major morbidity (OR = 31.08; 95%CI [29.51-32.65]; P = 0.028).<b>Conclusions:</b> Increased creatinine levels were found to be a significant modifiable factor for major morbidity after ventral hernia repair in cases with cirrhosis. This finding underlines the impact of preoperative medical management of cirrhotic patients on postoperative outcome in this patient population.

A two-sample Mendelian randomization study reveals the causal effects of statin medication on gut microbiota abundance in the European population

Background

Observational studies have reported changes in gut microbiota abundance caused by long-term statin medication therapy. However, the causal relation between statin medication and gut microbiota subsets based on genetic variants remains unclear.

Methods

We used genome-wide association study (GWAS) data on statin medication from the FinnGen database and gut microbiota abundance GWAS data from the IEU OpenGWAS project. A Mendelian randomization (MR) analysis was conducted to evaluate the causal effect of statin medication on gut microbiota abundance using the inverse variance weighting (IVW) method, MR-Egger regression, and weighted median approach. Meanwhile, heterogeneity and pleiotropy analyses were also undertaken in this study.

Results

Statin medication was negatively correlated with five species of gut microbiota abundance: Parabacteroides (BetaIVW = -0.2745, 95% CI = (-0.4422, -0.1068), and P IVW = 0.0013), Ruminococcaceae UCG-009 (BetaIVW = -0.1904, 95% CI = (-0.3255, -0.0553), and P IVW = 0.0057), Coprococcus 1 (BetaIVW = -0.1212, 95% CI = (-0.2194, -0.0231), and P IVW = 0.0154), Ruminococcaceae UCG-010 (BetaIVW = -0.1149, 95% CI = (-0.2238, -0.0060), and P IVW = 0.0385), and Veillonellaceae (BetaIVW = -0.0970, 95% CI = (-0.2238, 0.0060), and P IVW = 0.0400) and positively correlated with one species of gut microbiota: Desulfovibrio (BetaIVW = 0.2452, 95% CI = (0.0299, 0.4606), and P IVW = 0.0255). In addition, no significant heterogeneity or pleiotropy was detected in the abovementioned gut microbiota.

Conclusion

This Mendelian randomization analysis indicates a causal relationship between statin medication and six gut microbiota species. These findings may provide new strategies for health monitoring in populations taking long-term statin medications.

Molecular characterization of the histopathological growth patterns of colorectal cancer liver metastases by RNA sequencing of targeted samples at the tumor-liver interface

The behaviour of metastases in patients with liver-metastatic colorectal cancer (CRC) is still not adequately considered during treatment planning. However, studies in large cohorts have shown that the disease course in these patients depends on the histopathological growth pattern (HGP) of the liver metastases, with the desmoplastic (or encapsulated) pattern responsible for a favourable outcome and the replacement pattern for an unfavourable course. To increase our knowledge of cancer biology in general as well as to design clinical trials that take into account the diverse behaviour of liver metastases, it is necessary to know the cellular and molecular determinants of these growth patterns. For that purpose, we compared the transcriptome of tumour tissue (prospective cohort; n = 57) sampled very precisely at the transition of metastasis and adjacent liver, between the desmoplastic and replacement HGP. In addition, the mutational profiles for 46 genes related to CRC were extracted from the RNA sequencing reads. First, we show that the genetic constitution of a liver metastasis from colorectal cancer does not determine its HGP. Second, we show clear differences between HGPs regarding the expression of genes belonging to the Molecular Signatures Database hallmark gene sets. Biological themes of the replacement HGP reflect cancer cell proliferation and glucose metabolism, while the desmoplastic HGP is characterized by inflammation and immune response, and angiogenesis. This study supports the view that HGPs are a reflection of the biology of CRC liver metastases and suggests the HGPs are driven epigenetically rather than by specific gene mutations.

Effect of bariatric endoscopy on liver fibrosis and steatosis and the course of NAFLD - a prospective interventional study

INTRODUCTION AND OBJECTIVES

With increases in obesity and metabolic syndrome because of lifestyle-related factors, the prevalence of non-alcoholic fatty liver disease (NAFLD) also is increasing worldwide. In a subset of patients with NAFLD, an inflammatory process arises in the steatotic liver, known as non-alcoholic steatohepatitis, that leads to liver fibrosis and liver cirrhosis. In selected patients with obesity, bariatric surgery, and bariatric endoscopy are important therapeutic options.

MATERIALS AND METHODS

This prospective interventional pilot study was conducted to investigate two types of intragastric balloons (IGB). The IGBs were the Orbera and the Spatz3. Liver fibrosis changes were monitored non-invasively using point and 2D shear wave ultrasound elastography (SWE) and transient elastography that allowed for quantification of liver steatosis using the controlled attenuation parameter (CAP). Patients were followed for 12 months.

RESULTS

Of 34 patients implanted with an IGB, 30 completed follow-up at month 12; results for one patient were excluded because of initiation of obesity pharmacotherapy. Fifteen patients received the Orbera IGB, and nineteen patients received the Spatz3 type. In month 12, total and excess weight loss was 7.88 % and 30.13 %. Elastography values decreased from baseline (3.88 kPa) to 3.61 kPa at month 12 (p 0.024). 2D SWE values decreased from baseline (5.42 kPa) to a value of 4.91 kPa at month twelve (p 0.135). Transient elastography values decreased from baseline (5.62 kPa) to a value of 4.17 kPa at month twelve (p 0.009).

CONCLUSIONS

Bariatric endoscopy in the form of IGB implantation leads to weight reduction and improvement of liver fibrosis and steatosis.

CLINICALTRIALS

GOV REGISTRATION

NCT04895943.

Repeated dosing of AAV-mediated liver gene therapy in juvenile rat and mouse models of Crigler-Najjar syndrome type I

Crigler-Najjar syndrome is an ultra-rare monogenic recessive liver disease caused by UGT1A1 gene mutations. Complete UGT1A1 deficiency results in severe unconjugated hyperbilirubinemia in newborns that, if not treated, may lead to brain damage and death. Treatment is based on intensive phototherapy, but its efficacy decreases with age, rendering liver transplantation the only curative option. Adeno-associated virus (AAV)-mediated gene therapy has shown long-term correction in adult patients, but loss of viral DNA and therapeutic efficacy are expected in younger patients associated with liver growth. Effective vector re-administration is hindered by anti-AAV neutralizing antibodies generated during the first administration. Here, we investigated AAV vector re-administration by modulating the immune response with rapamycin-loaded nanoparticles (ImmTOR) in Gunn rats (Ugt1a -/- ) and Ugt1a -/- mice. We administered a liver-specific AAV8 vector expressing a codon-optimized hUGT1A1 cDNA (1.0E11 vg/kg) in P25-P28 mutant animals and, upon loss of efficacy after 3 to 5 weeks, a higher second dose (1.0E12 or 5.0E12 vg/kg) was given. ImmTOR co-administration reduced anti-AAV neutralizing antibodies and immunoglobulin Gs generation in male animals of both models allowing effective re-dosing, underscored by a significant and long-term decrease in plasma bilirubin, although efficacy was affected by low-titer residual anti-AAV antibodies suggesting that re-administration in patients may require combination with other methods.

Thrombotic complications post liver transplantation: Etiology and management

Liver transplantation (LT) is the life saving therapeutic option for patients with acute and chronic end stage liver disease. This is a routine procedure with excellent outcomes in terms of patient survival and quality of life post LT. Orthotopic LT (OLT) patients require a critical care as they are prone to variety of post-operative vascular, cardiovascular, biliary, pulmonary and abdominal complications. Thrombotic complications (both arterial and venous) are not uncommon post liver transplant surgery. Such vascular problems lead to increased morbidity and mortality in both donor and graft recipient. Although thromboprophylaxis is recommended in general surgery patients, no such standards exist for liver transplant patients. Drastic advancements of surgical and anesthetic procedures have improvised survival rates of patients post OLT. Despite these, haemostatic imbalance leading to thrombotic events post OLT cause significant graft loss and morbidity and even lead to patient's death. Thus it is extremely important to understand pathophysiology of thrombosis in LT patients and shorten the timing of its diagnosis to avoid morbidity and mortality in both donor and graft recipient. Present review summarizes the current knowledge of vascular complications associated with LT to highlight their impact on short and long-term morbidity and mortality post LT. Also, present report discusses the lacunae existing in the literature regarding the risk factors leading to arterial and venous thrombosis in LT patients.

The assessment of impaired liver function and prognosis in hepatocellular carcinoma

INTRODUCTION

The impairment of liver function strongly limits the therapeutic options for hepatocellular carcinoma (HCC), and the assessment of liver function is key to finding the appropriate therapy for patients suffering from this disease. Furthermore, preexisting liver dysfunction has a negative impact on the prognosis of patients in addition to the malignant potential of HCC. Hence, defining the optimal treatment of patients with HCC requires a comprehensive examination with liver function being a crucial part of it.

AREAS COVERED

This review will provide an overview of the currently existing methods for evaluating the liver function in patients with HCC. Assessment of liver function includes scoring systems but also functional and technical methods. In addition, the role of these tests in different treatment facilities such as liver resection, transplantation, interventional and systemic therapy is summarized.

EXPERT OPINION

A comprehensive pretherapeutic assessment of the liver function includes laboratory-based scoring systems, as well as imaging- and non-imaging-based functional tests. Combining diverse parameters can help to improve the safety and efficacy of HCC therapy particularly in patients with compromised liver function. Future research should focus on optimizing pretherapeutic assessment recommendations for each therapy.